Abdominal aortic aneurysm (ruptured and intact)

Meet the patient

A 72-year-old male smoker collapses at home, then arrives complaining of tearing back and abdominal pain, pale, sweating, systolic 84. The nurse reaches for the fluid bolus to push the pressure to 120 and reaches for the CT scanner. Both reflexes will kill him — the fluid disrupts the retroperitoneal tamponade holding his bleed, and the CT delays the only thing that saves him.^[1]

Two questions decide his next hour: is this a rupture? (a clinical diagnosis made at the bedside, with the pulsatile mass and the confirmatory ultrasound of the aortic diameter) and can I get him to a clamp or a balloon in time? (the clock from rupture to control is the single determinant of survival). Hold those two questions and the rest of the protocol slots into place.^[1]

References13ShowHide

1. [1]Isselbacher EM, Preventza O, Hamilton Black J, et al. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines J Thorac Cardiovasc Surg, 2023.PMID 37389507
2. [2]Powell JT, Sweeting MJ, Thompson MM, et al. Endovascular or open repair strategy for ruptured abdominal aortic aneurysm: 30 day outcomes from IMPROVE randomised trial BMJ, 2014.PMID 24418950
3. [3]IMPROVE Trial Investigators. Comparative clinical effectiveness and cost effectiveness of endovascular strategy v open repair for ruptured abdominal aortic aneurysm: three year results of the IMPROVE randomised trial BMJ, 2017.PMID 29138135
4. [4]Greenhalgh RM, Brown LC, Kwong GP, et al. Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results: randomised controlled trial Lancet, 2004.PMID 15351191
5. [5]Prinssen M, Verhoeven EL, Buth J, et al. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms N Engl J Med, 2004.PMID 15483279
6. [6]Lederle FA, Freischlag JA, Kyriakides TC, et al. Outcomes following endovascular vs open repair of abdominal aortic aneurysm: a randomized trial JAMA, 2009.PMID 19826022
7. [7]Kim LG, P Scott RA, Ashton HA, et al. A sustained mortality benefit from screening for abdominal aortic aneurysm Ann Intern Med, 2007.PMID 17502630
8. [8]Sweeting MJ, Ulug P, Powell JT, et al. Ruptured Aneurysm Trials: The Importance of Longer-term Outcomes and Meta-analysis for 1-year Mortality Eur J Vasc Endovasc Surg, 2015.PMID 25981698
9. [9]Brewster DC, Cronenwett JL, Hallett JW Jr, et al. Guidelines for the treatment of abdominal aortic aneurysms. Report of a subcommittee of the Joint Council of the American Association for Vascular Surgery and Society for Vascular Surgery J Vasc Surg, 2003.PMID 12756363
10. [10]Kirkpatrick AW, Roberts DJ, De Waele J, et al. Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome Intensive Care Med, 2013.PMID 23673399
11. [11]Ashton HA, Buxton MJ, Day NE, et al. The Multicentre Aneurysm Screening Study (MASS) into the effect of abdominal aortic aneurysm screening on mortality in men: a randomised controlled trial Lancet, 2002.PMID 12443589
12. [12]Moreno DH, Cacione DG, Baptista-Silva JC. Controlled hypotension versus normotensive resuscitation strategy for people with ruptured abdominal aortic aneurysm Cochrane Database Syst Rev, 2018.PMID 29897100
13. [13]Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial JAMA, 2015.PMID 25647203